HomeMy Public PortalAbout5036 1/2 SERENO DR_Plumbing__' oVDtl19Ta50 APPLICATION FOR 'PLUMBING PERMIT 1
DIVISION OF BUUMING AND SAFETY'
t Department of County Eaglne /CSC
11 County of Lo. Angeles
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= WM J FOX COUNTY ENGINEER BUILDI
ADDREll
SS O/ ✓O l.T�i/P.ENO ��
CASRATT O GRIFFIN SUP T OF BUILDING
LOCALITY G
FOR APPLICANT TO FILL IN NEAREST
s
CROSS
OWNER �� DISTRICT NO G UP dZONE RUDY FOR IMSPPc 1011
MAIL
ADDRESS d O
/ INDUSTRIAL
CITY./N/1/ TEL NO WASAPPROV e.twwr iv.n
PLUMBER ���B�Y�E 7�� INSPECTION RECORD
ADDRESS 2M6 yY •11) ipl
CITY R San Gabiiel TEL ;AT. 042U li
LICENSENO 14015PIPJ
NUMBER TYPE OF FIXTURE OR ITEM ELE
ATERCLOSET (TOILET) S �
W
BATH TUB I v
SHOWER
LAVATORY (WASH BASIN)
KITCHEN SINK
DISHWASHER
LAUNDRY TUB OR TRAY
CLOTHES WASHER
TOTAL NO OD `APPROVALS
GAS SYSTEM OUTLETS 100 O7J PATE IN3 ECTO S SIGNATURE
WATER HEATER i 00 /1J UNDER SLAB WORK
lok
ROUGH PLUMBING 1G
PERMIT f 1 00
GAS PIPING
TOTAL FEE GAS VENT
I HEREBY ACKNOWLEDGE-THAT I HAVE READ THIS APPLICATION HOT WATER HEATER
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS RE6UL ING PLUMBING FIXTURES 1 ��
PLUMBING
1 HEREBY CERTIFY THAT 1 RLY TERED AN R GA TEST
LICENSED AS REQUIRED OS AN TT AND S OF It
CALIFORNIA OR THAT AY TH E NEA ABO UTI ITY CO NOTIFIED
DESCRIBED RESIDE L P
SIGNATURE
OFPERMITT E FINAL
WILLIAM J FOX COUNTY ENGINEER VALIDATION R A WOOD CHIEF IGLSO INSPECTOR
? I G3r8 4 6�R NAR 7 3 8.0 0 in
WORKERS COMPENSATION DECLARATION APPLICAT R PLUMBING PERMIT {�
I hereby affirm that I have a certificate of consent to self 7y�e7q u
` insure or a certificate of Workers Compensation Insurance CE 817(REV 10/81)
Po§certdteA coEEy thereaf (Sec 3800 lob C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyyNo UC5�y2y00!C Company AJ61-J-1421/A f/lel
❑o
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING y A7s
Certified copy is filed with the county building inspec- !ADORE55 [� Z rCU-
lion department /^/ /�-,, NUMBER FIXTURE OR ITEM ® FEE
Date 1r6� �AppltSonlJ t O&b2 ) LOCALITv r
WATER aosET
RIE
CERTIFICATE OF EXEMPTION FROM WORKERS BATH TUB CROSS ST
COMPENSATION INSURANCE OWNER j
(This section need nes be completed If the work Introlwd by SHOWER
the perself Is for one hundred dollars ($100)or leu] LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued 1 shall not employ any person in any manner SINK CITY TEL NO
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER.
NOTICE TO APPLICANT If after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code you must forth- CITY LAWN SPRINKLER SYSTEM TEL NO 941-9080 .
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO —3
LICENSED CONTRACTORS DECLARATION DISTRIQ.TJO� ,./ SSED By
I here affirm that I am licensed under GAS SYSTEM OUTLETS ����--`G77ss 6y
Try provisions of Chapter 9
(commencing with Section 70DO) of Division 3 of the Business OUTLETS OVER
and Professions Code,and/may license is in full force and effect / 5 PER SYSTEM FINAL��J �f) VALID ON y
License Number 4160 ", Lic Class 0-3(0 DATE ( a
W 1rd FNy- 7-7_5-87
FINAL
Connector Date d'
❑
1 am exempt under Sec c0i
B 8P C for this reason U
Plan check fee p•
/� Dote
S gnatureUj2ic (y Q /17 PLUMBING PERMIT ISSUING FEES loop Tis Z
TOTAL FEE
Plan check applicant
SINGLE FAMILY ;2 6 8 Q 2{(
HOME OWNER BUILDER DECLARATION Name # s e e e e 5
I hereby affirm that I am exempt from the Contractor s License address
Law for the following reason (Section 7031 5 Business and
Professions Code) • City Tel No I e -,165,0
❑ I, as owner of the property will do the work and the • ' • 1 &502i
structure is not intended or offered for sale (Secaon ' ►
7044 Business and Professions Code) 04.03t87
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec 3047 Cw C )
Lender s Name
Lender's Address
I certify that I hove read this application and state that the
above information is correct I agree to comply with all County
ordinances and State jaws regulating iPlumbi ng and hereby
authorize reprelentotives of this County to enter upon the
above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
a•_ f ���Arx�» 2 Z5-$7
Signature of Permittee Dote